mpmiola

As per CAP standards TRM.30575 Misidentification risk: Verify ABO/Rh on second sample prior to transfusion and TRM.40670 ABO Group and Rh(D) type verification,  we order a non-billable TYPE2/WEAKD and result to meet the requirement for electronic crossmatch and/or type specific blood to be issued on a patient with no historical data.  This a new order/draw.. specimen must have blood bank id documented on tube by collector at time of collection in the presence of patient. if a second sample cannot be obtained and there is no documented previous ABO/Rh, immediate spin crossmatch performed using non type specific blood. if the phlebotomist is still on duty and has a clear recollection of patient they may be allowed to take tubes from earlier draw to patients bedside to re-identify patient and sample, placing blood bank id sticker on that tube. we usually use CBC tube from am draw. anytime a type and screen ordered on hosp patient the phleb asks the bb tech if a prev type exists if not a type2 is ordered on new order number requiring second venipuncture.
are your bedside test cards properly labeled date/time/init blood bank id, patient LIS label /order label to compare to patient wristband? are the results entered into patient chart?
 
 

Thank you R1R2 and AMcCord by the contribution

So, a pregnant woman tests 1+ pos with anti-D.  Do you give her RhIg?  She has many (MANY) Rh pos cells of her own, will the RhIg simply attach to those cells.  What if she tests 2+?  What if she previously tested 0 (prior method for us was solid phase (or tube)) and now tests 3+, do you change her type?  Do you give her RhIg now because you used to call her Rh neg even though now you call her Rh Pos?  What if you didn't have a prior type on her, you'd only know her as Rh pos.  What do you tell the docs when you gave her RhIg at 28 weeks when she tested 1+, but now tests 3+ and you call her Rh pos and don't recomend RhIg?
We are having more and more trouble, no idea why this seems "new" to us.  We currently have a pregnant woman who tested 4+ with anti-D in gel and has a history (at another facility) and anti-D and anti-E.
The more we talk about this the more confused we (I) get.

Typically expiration dates are established by the manufacturer. They perform stability testing for the duration of the assigned expiration date to support it with data. Data shows the product is capable of performing up until the claimed expiration date. It may continue to function they just do not have data to support it.
This should be done to support any "reagent" made that is not at least qualified in some way each day of use. Assigning an expiration date based upon the shortest dated component is not very good science. The different ingredients could be compatible with each other or could have a negative impact to on another. From a pure scientific and quality aspect one would prepare a reagent and place it on a stability schedule and test it periodically for performance. This data is then used to support the use. Any assessor should accept this science.
A simple analogy I like. If you made a cake today with milk that had a use by date of tomorrow does that mean the cake is not good after a day. Of course not, since it is now in a different form and could be stored in a different way. 

In my house, the cake would not make it to the next day.

Because of the rare risk of a fatal hemolytic reaction, we only use washed group O red cells for our premature newborns.  For other newborns and readmits we use ABO identical unless there is detectable maternal anti-A and/or anti-B, in which case we again use washed group O's.  There is about 20-40 ml of residual plasma in almost all red cell units, more than enough to cause severe hemolysis in rare instances.  We should not ignore that risk for our own convenience/inventory management/etc. in my view.  We only transfuse unwashed group O red cells to patients of unknown ABO type in emergencies.
 
There is additional evidence that ABO non-identical transfusions of incompatible antibody or soluble antigen causes harm to patients, in addition to the rare risk of life-threatening hemolysis.  We have published a summary of this evidence.
 
Is It Time to Reconsider the Concepts of "Universal Donor" and "ABO Compatible" Transfusions?
Refaai MA, Cahill C, Masel D, Schmidt AE, Heal JM, Kirkley SA, Blumberg N.
Anesth Analg. 2018 Jun;126(6):2135-2138. doi: 10.1213/ANE.0000000000002600. 

Most patients only need one red cell for surgery, or less.  The need for the second is usually emergent and there is insufficient time for washing (takes at least 30 minutes).  Just logistics and demographics.  Ideally, all patients would receive washed red cells, but there is not yet convincing data that clinical outcomes are improved.  There were trends to improved outcomes in our randomized trial (mortality in particular) but the trial was powered to demonstrate that washed red cells reduced post-transfusion reduced inflammation, as measured by IL-6 and CRP, which was conclusively demonstrated.

Most developing clinically significant alloantibodies still react at 37oC, and so trying to detect them at room temperature is more or less futile as, in most cases, all you will detect are antibodies that  you do not want to detect, such as cold-reacting anti-M, anti-N, anti-P1, etc, which would be a waste of time, reagents and, most importantly these days it would seem, money.
Most polyspecific or broad-spectrum AHG reagents these days are a mixture of anti-IgG and anti-C3d (particularly in the UK).  They do not contain anything but the merest hint of an anti-IgM (certainly, they would not be CE-marked for anti-IgM).  The other thing is that I am prepared to bet quite a lot of money that your laboratory is using EDTA-anti-coagulated samples.  This means that the Ca++, Mg++ and Mn++ ions are all chelated from the plasma, which means that the complement pathway cannot be initiated in vitro, so, even if the de novo antibody was capable of "fixing" complement, the anti-C3d would not detect such an antibody anyway.
Therefore, as the number of recently transfused patients who are developing antibodies not yet detected by normal serological techniques who have been fatally affected by a further transfusion hasn't been great (zero in fact) and the same applies to pregnant ladies, stick to trying to detect clinically significant antibodies at 37oC using monospecific anti-IgG.
GOOD QUESTION THOUGH - SHOWS YOU ARE THINKING!

This is a controversial subject. Firstly, ABO identical is by the most effective and safest. ABO mismatched platelets are associated in randomized trials with a 2-5 fold increase in refractoriness to transfusion, with is in itself associated with early mortality.  ABO mismatched platelets in observational studies are associated with increases in febrile transfusion reactions, allergic transfusion reactions, increased bleeding and mortality.
Is a single transfusion likely to be lethal? Probably not, but the blithe use of any old ABO type for multiple transfusions is highly likely to cause morbidity and mortality.  In a pinch, when the ABO is not known or ABO identical aren't available, washed or plasma reduced group O platelets are probably safest.  If not available, group A is probably safest.  My last choice in all instances would be plasma replete group O, because there is a tiny but real risk of a fatal ABO hemolytic reaction due to the 250 ml of incompatible plasma.  Incompatible antigen is probably less risky, hence the recommendation of group A platelets. Group A plasma has anti-B, which is the least dangerous of the two isoagglutinins in every respect.  
 
Is It Time to Reconsider the Concepts of "Universal Donor" and "ABO Compatible" Transfusions?
Refaai MA, Cahill C, Masel D, Schmidt AE, Heal JM, Kirkley SA, Blumberg N.
Anesth Analg. 2018 Jun;126(6):2135-2138. doi: 10.1213/ANE.0000000000002600.
 

This is me going back to the early 1970s, when I was first working at the International Blood Group Reference Laboratory (IBGRL) when it was still in London, and so my memory might not be 100% reliable, but I'll have a go.
Obviously, in those days we used to use polyclonal anti-A or anti-B that was derived from human donors, rather than monoclonal antibodies (essentially, there were no such things in those days).  We did know enough, however, not to use anti-A,B from group O donors, because of the chance of cross-reaction.
We incubated the red cells against the antibodies at 4oC for about an hour, and then washed them at least six times in normal saline (we didn't even use buffered saline in those days).  The last wash was kept as a negative control.
Next comes the clever bit.  We used heat elution at 56oC, as did many people, but the really clever bit was the way we kept the supernatant at 56oC during the centrifugation stage, so that the antibodies would not go back onto the antigens as the tests cooled down.  The Director of the IBGRL at the time was the late, GREAT Dr Kenneth Goldsmith (I use the term "great" advisedly).  He built a wooden box that contained the centrifuge, but also had a common light bulb in it that heated the entire contraption when turned on (we had to turn it on a good half an hour before we used it, to allow it all to come to temperature), but the whole contained a thermostat, so that the temperature as close to 56oC, so that a higher temperature did not denature the antibody, and a lower temperature did not allow the antibody to go back on to the antigens (he really was an amazing person - a doctor who was also an expert scientist).
The eluate and the last wash were then tested against A1, B and O red cells at room temperature (23oC incubator), which, of course, all acted as internal controls.
Later, we realised that the Lui elution technique (using melting ice) was a more efficient technique for eluting ABO antibodies, but everything else (barring the heated centrifuge) was the same.
Nowadays, we hardly ever bother.  It is very time consuming for virtually no return.  If the subject is a patient, we would transfused group O red cells, and if the subject is a donor, it is cheaper and simpler to exclude them, as long as they are counselled, to ensure that they do not feel "stigmatised".

They are from different clones and titer.
We repeated the blood group using BioRad Newborn Card and it showed 2+ with anti-A,B but negative with anti-A.

The rationale for irradiation is that congenital cardiac anomalies are associated with immune deficiency syndromes.  Some of these are not easy to diagnose in the first months or even first few years of life.  Our own policy is for infants and younger children (<5 years of age) to transfuse only irradiated, ABO identical red cells and the first red cell is washed.  We only wash red cells <21 days of age because of data that washed red cells are associated with less inflammation and clinical complications if of shorter storage (<21 days), but greater inflammation and poorer clinical  outcomes if >28 days of storage.
Pediatr Crit Care Med. 2015 Mar;16(3):227-35
Despite the long standing policy of using "fresher" red cells for these patients, the safest red cells are probably about 10-21 days of storage according to our data and meta-analyses of the randomized trials.  Fresher red cells are associated with a higher incidence of post-operative infections, the major cause of morbidity and mortality in this population.  I would never transfused red cells <7-10 days old to any patient at this point in time.  We have some mechanistic data that is as yet unpublished that the mechanism is dysregulation of oxidation/reduction in freshly collected red cells.
Blood. 2016 Jan 28;127(4):400-10
Washed red cells reduce the risk of post-operative inflammation in the only published randomized trial and there is also a trend towards reduced mortality in the washed arm of the study.  This may be controversial but it's the only data we have to go on, certainly the only randomized trial.
Pediatr Crit Care Med. 2012 May;13(3):290-9.
 
 

We use fresh (less than seven days old) irradiated RBCs.  We wash the units only if they are not fresh.

Yes, but c.261delG characterizes deleterious O alleles and is not present in alleles A. If this mutation is homozygous, I would suspect a cross-reactivity.

I also agree with the subgroup of A. However, I would do other tests before considering the case as resolved.
1. Are the reagents you used from different manufacturers from the same clone? Do they have the same title? Differences in clone or titer may lead to differences in reactivity.
2. Tn antigens may be cross-reactive with some anti-A antibodies. Treatment of RBCs with the enzyme may help to exclude this interferant.
3. I would or would refer you to the molecular investigation to identify the deletion mutation at position 261 of exon 6, which characterizes O alleles.
4. Flow cytometry can also assist in the evaluation of the mixed field. Is it happening because of poor reactivity or chimerism?

Very true.

Yes, but c.261delG characterizes deleterious O alleles and is not present in alleles A. If this mutation is homozygous, I would suspect a cross-reactivity.

In a rush, as I am lecturing in 8 minutes, but, if you can get hold of Klein HG and Anstee DJ, Mollison's Blood Transfusion in Clinical medicine. 11th edition, 2005, Blackwell Publishing, look at page 683, Sensitivity to latex and page 691, Toxic substances in plastic.
Sorry to be so brief.

Thank you all for your input.  With regard to the comment that the post was long....I tend to like to explain things thoroughly so readers have all of the information I have, and know what my thoughts are up to that point.  Sorry, just my style.
ABsub did also occur to me, but in all honesty, I have only rarely seen this in my 30+ years (just lots of AsubB).  Also not sure if it was just weak due to age so would not want to "label" them as ABsub if 6 months from now, they typed 4+ with Anti-B.   So was a little nervous about coming to that "official" conclusion.  So we did make the recommendation that if they really wanted to know, they could try submitting a new specimen in about 6 months. I agree that there could be a different Low Incidence Antibody that caused the transfusion reaction (we only tested what we could get from our panels).  We are sending pre and post specimen plus leftover platelets to the Red Cross to see what they come up with.  They may or may not elect to run a panel of some Low Incidence Antigens from their frozen inventory; but of course they can't test every Low Incidence Antigen so it would just be a "hit or miss."  But I guess what is still just odd to me is that the DAT was negative before the transfusion (just that morning; was just sent because the patient was being seen by their Oncologist and has been using blood products steadily, so they wanted us to have a specimen available should they need to transfuse more RBCs in next few days); then clearly positive right after the transfusion; and there was definitely an Anti-Lua coating the cells (but also a mystery as to why the strength of the DAT would so obviously weaken in just a few hours, if no evidence of hemolysis).   Also, with regard to the comment from BankerGirl about why we were calling it a hemolytic transfusion reaction.  We had called the Red Cross Medical Director right after we discovered the Positive DAT and he instructed us to do that; however, our Medical Director did not state that on the Transfusion Reaction Report; but in fact, stated that the reaction may not have even been related to the transfusion; could have been coincidental timing (but that still doesn't explain a Negative DAT becoming Positive from Pre to Post).   So is the suggestion then that while we eluted the Lua.....that had we performed an eluate on the negative DAT cells from the morning, we may also have eluted it then but it is just that it is not present on enough cells to have resulted in the Positive DAT (i.e. as an explanation as to why the DAT changed but no Anti-Lua was identified in the platelet plasma)?  I am still trying to make sense of that part; that if it was not the cause of the reaction and was not in the platelets, the assumption would have to be that it was already present and coating the cells prior to the transfusion; just not enough to cause a positive DAT; but enough to come off in a concentrated eluate?   The patient had received numerous red cell transfusions over a long period of time; so there certainly could have been a small population of transfused cells that were Lua POS to which the patient's Anti-Lua attached?  Also, Antibody Screen Negative, so no "free" Anti-Lua (unless low titer). If Red Cross comes up with anything more concrete, I will pass that along; but I really appreciate your input on this mystery! Brenda Hutson
 

IN the UK, the NHSBT (at least) has been performing titrations of all antibodies, of all specificities, in gel, after an extensive amount of work performed by my friend Gordon Burgess showed that there was very good correlation between these titres and those obtained by tube technique.

Sorry Scott, but could I just jump in here?  The strength of the reaction of the DAT is not a measure of anything really.  It is rather like saying that, if a reaction with anti-D from a pregnant woman is weak, the foetus is not in danger, but I have seen a few cases over the years where the reaction with R1R1 and R2R2 screening cells and panel cells has been weak because the D antigen sites are swamped.  The same sort of thing can happen with the DAT.

I would review some of these references with your pathologist. It's definitely not an exhaustive list.
Judd, W. J., Butch, S. H., Oberman, H. A., Steiner, E. A. and Bauer, R. C. (1980), The Evaluation of a Positive Direct Antiglobulin Test in Pretransfusion Testing. Transfusion, 20: 17–23. doi: 10.1046/j.1537-2995.1980.20180125036.x
Judd, W. J., Barnes, B. A., Steiner, E. A., Oberman, H. A., Averill, D. B. and Butch, S. H. (1986), The evaluation of a positive direct antiglobulin test (autocontrol) in pretransfusion testing revisited. Transfusion, 26: 220–224. doi: 10.1046/j.1537-2995.1986.26386209372.x
Stec, N., Shirey, R. S., Smith, B., Kickler, T. S. and Ness, P. M. (1986), The efficacy of performing red cell elution studies in the pretransfusion testing of patients with positive direct antiglobulin tests. Transfusion, 26: 225–226. doi: 10.1046/j.1537-2995.1986.26386209373.x
Domen R.E. and Grattan J. (1986). Efficacy of performing red-cell antibody elutions in patients with a positive direct antiglobulin test, Vox Sang, 51:324-326.
Johnson, M.F.M. and Belota, M.K. (1988). Determination of need for elution studies for positive direct antiglobulin tests in pretransfusion testing, Am J Clin Pathol, 90(1):58-62. doi: 10.1093/ajcp/90.1.58
Perkins, J.T., Arruza, M., Fong, K., Sosler, S.D., and Saporito, C. (1990). The relative utility of the autologous control and the antiglobulin test phase of the crossmatch, Transfusion, 30: 503-507. doi: 10.1046/j.1537-2995.1990.30690333479.x
Richa, E., Benidt, G., Tauscher, C., Stowers, R., Bryant, S., and Stubbs, J. (2007). Eluate testing following microscopically positive direct antiglobulin tests with anti-IgG, Ann Clin Lab Sci, 37(2):167-169.
Yazer, M. H. and Triulzi, D. J. (2009), The role of the elution in antibody investigations. Transfusion, 49: 2395–2399. doi: 10.1111/j.1537-2995.2009.02304.x

The Circular of Information for the use of Human Blood and Blood Components has information regarding transfusion within 4 hours.  Here is an excerpt:  "Transfusion should be started before component expiration and completed within 4 hours."  And another, "The initial portion of each unit transfused should be infused cautiously and with sufficient observation to detect onset of acute reactions. Thereafter, the rate of infusion can be more rapid, as tolerated by the patient’s circulatory system. It is undesirable for components that contain red cells to remain at room temperature longer than 4 hours. If the anticipated infusion rate must be so slow that the entire unit cannot be infused within 4 hours, it is appropriate to order smaller aliquots for transfusion."

Hi Cliff.  We do 4 hours from the time the unit leaves the blood bank.   We use a electronic time stamp to document this time on the blood administration tag that is attached to the unit.  We teach the nurses that they have 4 hours from this time to complete the transfusion.   This does not apply if we send products in a cooler.   

I don't want to get you into trouble, but I would suggest that you gently persuade your manager to either read (and take notice of) BSH Guidelines or (or better still, and) contact an NHSBT Consultant to get advice/contact one of the writing group of the Guidelines (medically qualified, if necessary) to save him/her and his/her staff a lot of totally unnecessary work and expense (particularly as his/her budget is provided by British tax payers, of which I am one)!!!!!!!!!!!!!!!!!